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Online Self Referral Form

Please be aware: All fields are required

PERSONAL DETAILS

 

CONTACT DETAILS

ADDITIONAL INFORMATION

*:
Do you have a long-term condition?
If so, please specify:
Are you an ex-Armed Forces Veteran?
Are you a Carer for someone?

Employment and training support

We have Employment Advisers who are part of our team. They may be able to help you look for work or training, or help with applications or interviews. They can also help you negotiate your return to work with your employer or with job retention or conflict at work.

We see people with a wide range of needs. We want to be as helpful as possible. Answering the following questions will make sure we will be able to help you in the most effective way.

1. How often do you have someone (like a family member, friend or professional) help you read letters and information leaflets?
Never:
Rarely:
Sometimes:
Often:
2. How often do you have problems filling out questionnaires by yourself?
Never:
Rarely:
Sometimes:
Often:
3. Do problems with numbers make it difficult for you to manage day-to-day activities, such as paying bills and reading timetables?
Never:
Rarely:
Sometimes:
Often:

We are also trying to improve access to our services for people with learning disabilities. The following question will help us to work out how well we are doing.

4. Which of the following services have you received (please tick as many as apply)?

When we receive your information we will contact your GP to let him/her know that you have referred yourself to the service, and to request any further information that would be helpful to us.

A team member will aim to contact you within two weeks of receiving your information to explore the best way forward for you. Please make sure that you complete your contact details in full to help us with this process.

Talking Change
Psychological Services
First Floor, 8F The Pompey Centre
Fratton Way
Portsmouth
PO4 8TA

If you have any problems filling in the forms please contact us on:-
Telephone: 023 9289 2920
Fax: 02392 892947